Public Health Early Years
Case for Change
Ben Leaman & Kate Horne
Calderdale Council Public Health
April 2016
Cost
£332.37 – the unweighted spend per head on
children up to the age of 5 in Calderdale
£239.01 – the unweighted spend per head on
children up to the age of 5 in England
£248.75 – the unweighted spend per head on
children up to the age of 5 in Y&H
£286.00 – the unweighted spend per head on
children up to the age of 5 in CIPFA
Unweighted spend per child up to the age of 5 at LA level
(England)
£900
£800
£700
£600
£500
£400
£300
£200
£100
£-
Mean
average
Unweighted spend per child up to the age of 5 at LA level
(Yorkshire & the Humber)
£400
£350
£300
£250
£200
£150
£100
£50
£-
Mean
average
Unweighted spend per child up to the age of 5 at LA level
(CIPFA nearest statistical neighbours)
£400
£350
£300
£250
£200
£150
£100
£50
£-
Mean
average
Outcomes
 ¾ of mums initiate breastfeeding but only 2 in 5 are
still going at 6-8 weeks
 Life expectancy at birth continues to rise, but is still
a year lower than the England average
 1 in 3 children are not “school ready” at the end of
reception, increasing to more than half in those
eligible for free school meals
 Mums are greater than 20% more likely to be
smoking at time of delivery in Calderdale
compared to the England average
 More than 1 in 5 children are overweight or obese
when they start Primary School
Outcomes (continued)
 Children have an average of nearly two decayed,
missing or filled teeth at the age of 5 – twice as
high as the England average
 Nearly 1 in 10 infants don’t receive newborn
bloodspot screening in a timely manner
 Children up to the age of 5 are 10% more likely to
have a hospital admission for accidental or
deliberate injury
NB this focuses on the areas for improvement – we are
doing well in other areas!
Service user feedback
Online survey of service users (100 respondents)
 Support mainly comes from HV (88%), family/friends
(86%), internet (79%) and doctor (77%)
 Health professionals and settings rated as “good” or
“excellent”
 Perceived gaps in promotion of school readiness
and healthy eating, supporting emotional wellbeing,
and development/socialisation and preventing
childhood obesity, accidents and tooth decay
 Barriers perceived to be timing of sessions,
associated costs, location and self-confidence
Service user feedback
Online survey of service users (100 respondents)
Would like:
 Additional support during pregnancy: Breastfeeding,
preparation for parenthood, continuity of care
 Additional support during first few weeks:
Breastfeeding, emotional support, ongoing
support/advice/visits
 Additional support during first year: Breastfeeding,
emotional support, ongoing support/advice/visits
 Additional support during preschool years: child
development and socialisation, school readiness
Service user feedback
In-depth focus groups (27 participants)
Overview of Health Concerns
 Parents were satisfied with the support received by
secondary care and health visitors. In some cases
however parents did not feel concerns were taken
seriously by GPs and spoke of ‘going round in circles’
before a condition or concern was appropriately
acknowledged and treated/supported.
 Parents, and particularly first time parents, felt it was
not always straightforward to know who to contact if
they have a concern.
Service user feedback
In-depth focus groups (27 participants)
Infant Feeding
 Infant feeding is more than just breastfeeding, and
the focus should change accordingly.
 The way weight loss is managed in infants by health
professionals could be improved.
 ‘Feeding on demand’ is promoted sometimes to the
neglect of parents’ overall wellbeing and exhaustion,
leading to converting to bottle-feeding.
 For some parents the ‘push’ on breastfeeding is to
the detriment of information and advice being given
to those who choose or need to bottle-feed.
Service user feedback
In-depth focus groups (27 participants)
Healthy Lifestyles
 In general parents didn’t feel they had the amount of
information and support they needed in terms of
lifestyle, diet and exercise for their children
 Very few parents knew that three hours per day is the
suggested amount of physical activity for toddlers.
 Parents of children with specific dietary requirements,
experiences wait a long time for a diagnosis and
struggle with the dietary requirements of their
children.
Service user feedback
In-depth focus groups (27 participants)
Health Visiting
 Overall, parents were happy with their health visitors
and had been able to forge good relationships.
 The key to good relations was consistency and
continuity of provision of care
 Advice and support in the area of healthy lifestyles
was lacking
 Although affecting only a minority, the response from
health visitors (and GPs) to allergies also seems to
represent a gap in knowledge which parents
struggled with.
Service user feedback
In-depth focus groups (27 participants)
School Readiness
 Parents struggled to pin down what exactly school
readiness meant: for some it was potty training,
holding a pen, being immunised, being emotionally
ready as well as intellectually prepared.
 There were many definitions provided by parents
along with a feeling of confusion around who should
be providing school readiness help and advice.
 Parents wanted more information on this area as they
felt it was very important and a crucial stage in their
child’s life which they wanted to get right.
Service provider feedback
Online survey of service providers (24 respondents)
 Key concerns about parents: healthy eating, emotional
wellbeing, smoking, financial concerns, preparation for
parenthood, breastfeeding
 Key concerns about children: Growth/development,
weaning, oral health, child development and
socialisation
 Perceived gaps in promotion of school readiness
 Perceived gaps in supporting emotional wellbeing
 Perceived gaps in preventing tooth decay
Public Health Early Years
A New Model for
Calderdale
Ben Leaman & Kate Horne
Calderdale Council Public Health
April 2016
New Service Model Vision
“An integrated public health early years service,
covering preconception through to pre-primary school,
that prioritises giving every child the best start in life and
contributes to ensuring children in Calderdale are
happy, healthy and safe - reducing health inequalities
across the life course, and other social and economic
inequalities throughout life.”
What does ‘integrated’ mean?
Service coverage
 Residents of
Calderdale
 Doesn’t include
those on GP list
who are outside of
the Local
Authority area
 From preconception to preprimary school (-1
to 5)
Service Principles











Built around the Health Visitor ‘4,5,6’ model
Outcomes focussed
Universal service for all
More intensive service for those that need it
Enhanced model of peer support
Appropriately skilled workforce, with appropriate skill mix
More of a focus on prevention
Clear models of transition into and out of service
Avoiding duplication within the system
Overall goal of reducing inequalities
Committed to care in the home
Critical service interactions
 HVs will be part of
practice team
 Each GP will have a
named service link
 There will be
specific leads for
specialist areas
 IT really important!
 Safeguarding is too!
Meeting Council objectives
Fairness
 Improve access for children and their families/ carers
 Improve outcomes, in particular public health
outcomes, for all children
 Reduce inequalities and tackle disadvantage
Sustainable economic growth
 Raise aspiration and achievement for all our
residents
 Manage demand and invest for the future
 Drive economic development and enterprise
Public Health Early Years
What next for FNP?
Ben Leaman & Kate Horne
Calderdale Council Public Health
April 2016
FNP – a primer
FNP is a voluntary, preventive programme for
vulnerable young first time mothers. It offers intensive
and structured home visiting, delivered by specially
trained nurses, from early pregnancy until age two.
FNP has three aims:
 to improve pregnancy outcomes
 improve child health and development
 improve parents’ economic self-sufficiency
FNP outcomes
Primary
 Smoking rates in pregnancy
 Birth weight
 Subsequent pregnancies in next 24 months
 Hospital (A&E) admissions
Secondary
 Breast feeding rates
 Infant health and development
 Mother’s mental health
 Participation in education and employment
 Referrals to other services
The problem…
Cost
 Nationally estimated at £3000pa per client (2008)
 Locally estimated at circa £3750pa per client (2016)
Evidence
 Predicated on American model (no Health Visitors)
 “Adding FNP to the usually provided health and
social care provided no additional short-term benefit
to our primary outcomes. Programme continuation is
not justified on the basis of available evidence”
Lancet 2016
The problem…part two…
Scope
 Only young first-time mums
 Doesn’t necessarily target those most at need
 Very rigid in approach (we can’t influence it)
 Intensive only means weekly moving to monthly
 Can lead to reliance on the FNP nurse
Crossover
 With other commissioned service caseloads




Health Visiting
Midwifery
Family Support / Family Intervention Team
Children Looked After
Future delivery model
Three options:
 Continue with FNP
 Don’t commission anything for vulnerable cohort
 Commission new model of care
Option 1 – continue with FNP
Positives
 Easy option
 Less politically toxic
Negatives
 Evidence base lacking
 Others decommissioning around the country
 Relatively expensive
 Limited influence over content (national programme)
 Only targets age and deprivation as marker of
inequality
Option 2 - Decommission
Positives
 Frees up financial resource
Negatives
 Doesn’t fit with LA obligation to reduce inequalities
 Potentially politically toxic
 Potential knock-on effect on other services
 Impact on relationship with provider
 Families on current caseload left with no service
Option 3 – new model of care
Positives
 Opportunity to support existing council service
 Opportunity to develop a model that better targets
inequality
 Free up financial resource (more for less)
 Move away from constrictive model
Negatives
 Potential for political toxicity
 Loss of value that FNP national team bring
 Impact on relationship with provider
Example new model
Family Intervention Team (public health)
 A new arm of FIT team
 Based on existing model
 Has a focus similar to FNP in terms of outcomes already
 Already crossover in terms of caseload
 Intensive can mean daily





Ties into reducing demand on other services
Broader scope (broader measure of inequality)
Tailored to meet individual need
Supports existing council service
Delivers financial savings
Any questions?